HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (36) __
WORKERS'COMVENSATION�ECLARATION ����Y � - '�
I hermby affi�m fhat lwhave a cer}ificate of consent to self �
insure,or a certificate of Workers'Compensation Insurance, A�PLICAfiION�� FO�R�BCJI�L�DING�� PERMIT
� or a certitied mpy rhereot(Sec.3800,�ab.c.) COUNTY OF LOS ANGELES BUILbING AN6 SAFETY � `Q
PolicyNo. Company BUILDING
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN Aooeess � � � �
� Certified copy is filed with fhe county building inspec- 6UILDING//���^ / �A���� R � ,
tion deparfineM. ADDRE55 F! c) �ocr�urr
'a NEAREST
Date Applimnt CI7Y�L/E'AA��.L� /��' ZIP CROSSST.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF sLDGs. n55E550R
COMPENSATION INSURANCE SIZE OF LOT NOW ON tOT MAP BOOK PAGE PARCEL
(This section need nof be completed if the permit is for ane USE ZONE MAP
hundred dollars($100)or less.) TRAci e�OCK LOT NO. NO.
^ �p' .y.�y iEt. SPFCIAL }
I certify ihat in ihe performance of ihe work for which fhis OWNER(���4�" C/.h'p/.4'n NO. CONDITIONS �
permit i5 i5sued,I Shall not employ any pef50n in any manner �j DISTRICT GROUP TYPE FIRE PROCESSED eV �
so as to 6ecome subject fo the Workers'Compensation Lpws. ADDRESS.Z G? �` .-� ^ CON�/, ` _„ (� '�
:Z �rAJ 1 '�'(\\\ ;�
Date�Applicant ' � q a7Y / O (G�L� ZIP 1/ � �-� ��x- 4�
- yLs`�- STATISTICAL CLASSIFICATIDN APT. CONDO. �•
NOTICE TO APPLICANT: If, after ma ' g this Certificate of ARCHITECT OR tEL. y
Exemption, you should become subject Po the Workers' ENGINEER NO. CLA55 NO. DWELL.UNITS �
Compensotion provisions af fhe Labor Code,you m�st forth- A�DRE55 SEWER MAP �
with comply with such provisions or this permit shall be a
deemed revoked. GONTRACTOR �CJ� u�'f�d1�� NO. ��=5 ,o BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION - LIC.
I hereby affirm ihat I am licensed under provisions of Chapter 9 t1DDRE55 .jJ ��� NO. � �ej yq�ppTION
(commencing wifh Section 7000)of Division 3 of ihe Business and / LIC. ..
Profeuions Code,and my license is in tull force and effecL CITY�j�O�L�'r/L-'�� CLASS C�' $ ��l ►
P(y SQ.FT. NO.OF NO.OF CHECK
LicenSe Number 7J���� Lit.C�asS ��e�� SIZE STORIES FAMILIES ONE
��✓�uj ��fj f�� � �ESCRIPTION OF WORK NEW � $
Contractor Date ji "�--�L
�I am exempt under Sec `��js�-�� �C�,� ADD � �w ,
ALiER � FINAL ._ �! ,L A
DATE
B.BP.C.for lhis reason REPAIR � g:�e � m e 2 3
USE OF
Date: DEN,OL FINAL
EXISTING BLDG. 8y I " �"2`J�G G
Si naturC - APPLICANi _ TEI.J�
9 OWNER-BUILDER DECLARATION PRIM��J� , �'J-.pi No. i"' � •3 ���,'.^r
I hereby offirm that I am exempt from the Contractor's License .�- ,�I� � '- �''��"
Law for the following reason(Section 703L5, Business and ADDRE 3y�� �G�'� `✓�� , S
Professions Code): PRESENT
I i.C�-86
❑ �BUILDING
I, as owner of the property, or my employeas with nDortE55 r 3 4 1:3 r�.
wages as fheir sole compenwtion,will do ihe work and
Ihe structure is not iMended or offered for sale(Set}ion ����TY , fr.n x o a a ,
7044,Business and Professions Code). MOVING TEL.
OI,os owner of Ihe property,am exdusively confrociing �ONTRACTOR NO. � ' d e�C'. -Jr�
with licensed ContraCtOrS to[OnSfrUCt the proje[t(SeC- qDDRE55 1j �S
fion 7044,Business and Pro4essions Code). �y � �� � � s�Q�j U�
REQUIRED TOTALSE7BACKFROM ExIST. �/
CONSTRUCTION LENDING AGENCY SET BACK vnRD HWY PROA.LIN wiDTH ► �>'� � f 1.C��—�6
I h e r e 6 y a ff i r m�h a t t h e r e i s a c o n s t r u c ti o n l e n d i n g a g e n c y f o r FROM
the performance of the work 4or which this permit is iss�ed P.t. f
($ec 3097,Civ.C.). SIDE
- P.l.
Lender's Name '} '�P,
� Lender'S AdfJress P.0 Fee$ O� •� Permil Fee �/���
I certify that I have read ihis applicotion and state that the Issuanr.e Fee L V' �v
t above information is mrrecf.I agree 10 tomply with all County In�estigarion Fee
� ordinances ond Slate laws relating to building consiruction, Totol Fee °��'sV
6nd hereby authorize representatives of this Coonty to enter
� upon ih/e above-menrioned property for inspeciion purposes.
� 6 n � ���"'�,s---��� SEE REVERSE FOR EXPLANATORY LANGUAGE
narure of Appiiconr or Agent Doie �s
,.e...�....._,..,a.R.,._..., �s.;�;.� --*„--..-_-"'_--;-..., .--a.R-,�.��.s..�..- . _ ' .. .;_'.�-__»._ --,_.,.-�_„_...__._-,�_._..-.,- , . .. ... IVIV'�k-.3i.11.s'r.Fi�iJr.C�,ti?{.`1i.Gii
P1,9!f�3 i6?,�'41��P.39' INSF°&C�dR'S aY�°f'i'E4 �� _ .
--'.-"-�...�.-...m��� r-�.�-.»,--.... ..�.+�x.�+o:W,.�.e.,..-...,a . ---"" ,.--....-.-�..---.. . - - . .., I hereby a:`firro 4r.�t 1 ar.-�nxcm;n i+om t�,¢Cor'rccta•"s
Ye: S:aSurn�$ 9 License Law iur ihe�fc,lio.a��.�c� reason. (S�c. 703Y.51
A89rOvsad }--�— .—.-_—�----_- t;:ra{nss.s�%:�1?�•ej�x.rienxG'ur�r:i4.cgcie;:erea:.,r.tyu.�5;e.'�
fl;�.� 6a4 �� Ro. ��Da4o � _' ._—____ ;eyu;res a yr.- t �c;:, r c �1-er ' 6 _�e.�'rr.ssidsh,
_..- _.�.-r-.. ..�- ...-�- . ... �......,�,c-, c - t • -ie nso r��1^res
� I . . ... . - ... . - ' - , ' " _r�y b _ � x} - . .•-? -
�.-�' V_..,�____' i�fC^U�CtC1>, fOP- f. "l f"Y $7�P !(5 ?2Ni5 FS6fCiH,^,FC
- -'-- f6 4•L I>r f.0'LCG ,eLL�,s.,".n.�,3.8 LO.i C iJ tu[.�._5 O,t Je CQ'.-
I . i .. �.. • .• . ' . • •".�.• . . .: . t�!tn9'S 1.'_Cn.'l':,ttot'�i,'F..1�fteY%!I�C(IJNn_C:L":tiio r:';'Eir SC�C-
11'
I I ....�.._.. ..:..� ..:.�. .: . - .
� -- :aaa/U6U/oj tisrissor-5 n,f tbe!:±ss��-es:on�Fref:ssions
Co.(c1 oY!tia6 YC IS C.YeY!,(tr't>2rCET::ri3 aR[L 6'Im�Hasi.'fnY Ehe
. __r..._-..�..:.:...�._..��.......,..,,.._a,.e..�-., � ..._.,..:�...-..'-.,.-.rt- _ —�-_-_-__' .;Ptc,��,rt¢wen:;>'ier.l.r.y e:cau;,<rr�f�'^eii..sz%Ui1.�fiy
� '.e,.-su'srod � . c;:�•:.yplirc:e f r .- rr ".._ cp�,acuxt fn a cfr tl
� Y � ��_..__ t7A}tC i7.9S81J@4� ... . , "
:��� de€� � `l^:, rP10 or.Zpgrovmd r.;;t af��. ��r z e dr . ���-n_�s(ss(3Ji.;:
_� _€ 'j'� .,`L. I,as o c �ne properfv,o my r�pbyees w'h
Water C��tifie;rfc E�. .I . . . . a '----'"' ' vac�Ts as n�e - ccm��ensot`a�,vn�:dc•he work,and
"'i�L� _ ine str�ct�re s nor n'cnde o:ercc¢o sn e(Sec 7C<41
HealthCepurem;:rt _ - _ ' . . . ,, '..-,.y"--_.._.._ .Ss:,;,•:�r..:�.r;;i?•sn,`as.,:u�•>! : �..a . rcrsorcT.;rmss
___ � __,L_i � . � . T;arr�•l�:.zs:nn:�[;j;dN`•�ar3 n:c:ar nFnrn,eserty wno nuiids
� Fire Deper:mer,P � . -- , ----- - �rlsr.trn:vrs?6erer,a:,�+=;i s��;r�en^ss9ica a^cr'z bimseff nr
- t}r< � sis re ">l . . r�o;;dzu' th.�� :cc1'�,a-
� �G cding -__—_._._�_�_ __._ 17 . nR rt >;. t�' �nr�cifJ"cNvc'��or u� If.
� . ::oc.c er,z _- s.-r s .�ra p n:. sx� �rxs>/d::. hrc^zr
�Gool,::aico! . ____.. _-- ___., .y�,, u�'i.,:> .e.g - c.. r �ic f-r
i . ; I_� I � . . - ' ,. .c:o:Lzs�,f jo,.o,.?e-:. ,..x�._, _ �_,.....C... ,.7'. -.f,r
° x,
3nc�s.:z.�;.�e? c.IoJ.
r�_._�.________,
�Padss:r:c^Pro'uc°iun I .:. . ---.-__�____ . ' - : - ,
�(,Fenca)�:.a�o,r.y1 � . • � �� � _._. _.___ - 4 as o,n. ct�'^�F p cpe „,m_zdi-�s zt�cen`rn.--
L_.. _.tirrn�riin lic::nsee:<ontrectcrs tc c::^s!ruct'hc�ro;cc��Sac.
rSpeticl lsspcePian 70.54;ilzsi:as:�..��'�c�a��i�.sq'::a�c� l.:�a.i.e>w,tr¢etor'.a
(�_cnc.)(Nason;Yi�b'�e�dina)� I __�- . -_-_ ..;cccs ;-,,,'-�sn ��`zs�c_.. r._'�:: �<;Ji..:.�.•' ::
.� _ � ! � bu;F�::�:rr%;ri�7;ce=�s'_n¢`•q:r,rr.-;.:�::.vi.��c :>•ractstfor. c£;
Lo�iQrai�ega � I .. �.+._;, ._<_u ...>�..,. :.�"._..-'-"'"�.'-'- )?,yc�ec:s:'.>h e n.:,r�ec:�.�'aJ�e�ce;u�.��,;rcucssR fo t?e
� •
I ••�true•�,s's f.i�:e;r,r._.:iJ.
_'—:_—�' :,,,. :;. .....,
' ' ._.__-_ "—_'—__._____.__..._
�f'ar ng . - ._.. . .,... .. � ... . ,.,
—..__"'�__� ._ lumoxcmptund»rSaa,_ ,ti.-:�'.C.fc;Pl;l-
Ii -- .rs�r,_--------------- .
--�— -- '
�__._ � - -- -- o�,�— --_ --o�r�,z�_____—
_ ,: �
— n:F...� — -----
.
�A�S.r 3c s �'�tr� I n:a�xcd�r's 5ign�4ura � .. ... . .. M . �.. .
�'�j "__�
Locctio _ _�J�_-__-_--_.1 _ - ____-' --_ . .� . . ... . _ _`_ . .. .�.,._.�,.^
(Setbc.. �Y�:.�) �
=o��coP�o�3 � i — �- -- -- -- — — ,.
___ �--
siao ' — —_ _.,�, .
� ----
_.___f^__ �
I ------- --_..----- -- ---
— -------_
FYC L
` � �.. .
` .�J�.��.� � _ ____—" '__— __,.__—_____
_________._--_— ___
.y Ir,su!crion i � � � . . . �
E,,.ra ...__ l , :_:.
.._____. _ ___________.___......
_..
�ath./Gryv✓rl I- � ..__.-______._._______-_
In}erlor_____ � �I _-.
i t-
Lath-Eaterior —I � � ------'-- ---- .-- --_-�- -.- -- -- -- �
------
l_
Houae Numher- . . _ ' ., ,... .. ��...-- -. ., c.�:..,..:� ::.. —.��
Corteci&�os'ic3 �' _,___I.____ ` . .. .. " ..
__�-_�__ _._`__.___.__.. _._..__._�.__�.__.__.�.___-'_'
_.m,'�"._'__.
Finar- � . . . ..... .... . . . . .. . ... ,
Enfor on FrCn! .
,!�_J_ I ' ____�__.,___"__ ___--_____""______-"'___-"_'--�
�._.._._____.�_.�� �_._ i _ —__---- ___'_— __—_"___ —_——